Document Prostate Ultrasound and Biopsy Procedures

You can document the details of the prostrate ultrasound and biopsy procedures.

1. On the SOAP template, select the Procedures link.
   The Procedures template opens.
2. In the Genitourinary section, select Prostate Ultrasound/Biopsy.
   The Procedure - Prostate US BX template opens.

   

3. In the Indication section, do the following:
   1. Select Description, and select the diagnosis.
      The code is automatically filled.
   2. Select Status, and select the diagnosis status from the list.
4. To enter a saved default set, select Quick Load and Save.
5. In the Pre-Procedure Care section, select the appropriate checkboxes after explaining the procedure details to the patient.
   Note: To add more information about the consent, select the Consent link.
6. In the PSA Information section, enter the prostate-specific antigen and percentage of free prostate-specific antigen.
7. Enter the details of the pre-procedure medication, if any.
8. Select the digital rectal examination findings.
9. In the Anesthesia section, select the anesthesia given to the patient and then enter the lot number and expiry date of the anesthesia.
   • If the procedure is done without anesthesia, select None.
   • If the anesthesia is not in the list, select Other and enter the anesthesia details.
10. In the Ultrasound Findings section, do the following:
    1. Enter the prostate ultrasound findings.
    2. Select the appropriate checkboxes and options for the following:
       • Capsule
       • Lesion
       • Anterior fibromuscular stroma
       • Seminal vesicles
       • Bladder
    3. To enter any other finding, select Other findings.
11. In the Biopsy section, select the appropriate checkboxes and options to document the details of the biopsy, and enter the number of biopsies performed.
12. In the Gold Marker Placement section, enter the number of markers, and the lot number, and expiry date.
13. In the Post Procedure and Instructions Provided/Follow Up, select the appropriate checkboxes and enter the details.
14. To provide additional information, select Comments.
15. Select Save & Close.